In 2011 and 2012, I traveled the world in cooperation with Novartis to document the impact that malaria has on people — and to show that,with the right combination of know how, technology, resources, and collaboration, malaria can be beaten.

Through my photographs I witnessed the amazing story of the Novartis Malaria Initiative.

This massive program has delivered 600 million antimalarial treatments to adults and children in malari-infested regions across three continents

The following link will take you on a remarkable journey, from the creation of the antimalarial active ingredients in China, to the treatment of malaria patients in Africa and Asia.

(The following text has several contributors- primarily Joyce Ho, a Graduate Media Fellow from the Stanford School of Medicine and Leila Darabi from Planned Parenthood Global).

In Kenya, Planned Parenthood Global (PP Global) works with several local soccer leagues to integrate sexual and reproductive health education and services into their programs.

For many, expectations for their educational and career success do not extend beyond completing primary school. Some are already mothers. Joining an athletic league provides these young women with the chance to exercise, become part of a team, and have some fun. Evidence shows that young women who participate in team sports are more confident, stay in school longer, and set more ambitious career goals than those who never get to run across a field or score a goal.

Using their Youth Peer Provider model, PP Global’s partners train young people to become health educators and contraceptive counselors in their own right. Youth Peer Providers work closely with local clinics and are trained by public health experts to teach their peers how to avoid unwanted pregnancy and sexually transmitted infections, and to provide contraception to young people who need it. This peer-to-peer model circumvents the stigma and barriers that surround adolescent sexual and reproductive health services. In countries where talking to young people about sex remains taboo, Youth Peer Providers help their counterparts delay pregnancy, stay healthy, and stay in school.

We will follow two girls: Sylvia, who lives on in the Kilifi district on the coast of Kenya and Anne, who lives in an urban slum in Nairobi (names changed to protect their privacy).

In the Kilifi District on the coast of Kenya, HIV and teen pregnancy trap some of the world’s poorest and most disadvantaged adolescent girls in a relentless cycle of poverty. A local community organization called Moving the Goalposts (MTG) sought to address this issue by organizing a young women’s soccer league. By engaging these young women in physical activities that promote camaraderie, MTG helps its players build self esteem and leadership skills. The framework for MTG represented a unique entry point for reproductive health initiatives for these young women, to give them the knowledge and tools to protect their sexual health.

In 2011, MTG and Planned Parenthood formed a collaboration to build a sexual health youth peer provider program into the soccer league. Sylvia, age 22, is one of the first peer providers trained through the MTG and Planned Parenthood program in Kilifi. She plays on the older girls’ soccer league and teaches sexual health classes to her peers before games.

The unique quality of the peer provider program lies in increased access to the target population. Young people are hard to reach, especially in areas where enrollment in school is limited. Sometimes adults speak different languages from the younger generation, and oftentimes, youth shy away from asking questions about sexual health out of embarrassment or discomfort. Peer providers know exactly how to reach the ones they are trying to help – they know how to communicate effectively and lessons are safe places where girls can ask any sort of question and not feel embarrassed. Here, Sylvia demonstrates the proper way to use a condom while her teammates listen and learn.

A young woman in Kenya knows that if she gets pregnant, she will probably be forced to drop out of school and the course of her life will be unalterably changed, leaving her with very limited options. Through MTG and Planned Parenthood, these soccer players are becoming empowered to take their health needs into their own hands. Sylvia, a star player on her team, understands the importance of this program, and thus devotes many hours a week to peer counseling and soccer practice.

The girls don’t live close to the soccer fields. Many players walk miles from the slums to the more well-kept neighborhoods where the soccer games are held, demonstrating their true dedication to the program.

Sylvia lives at home with her mother, the head of the household, who is proud to have such a responsible daughter who spends time volunteering to help her community. Sylvia has an older sister who is currently married with children, and Sylvia wants to finish her education first before embarking on a similar life path.

Next year Sylvia plans to start classes at the local university. After finishing secondary school, she took time off to work and save up money, all the while debating whether college was within her reach. Sylvia’ experience with the team and the Youth Peer Provider program helped build up her confidence and plan for her future. This is in stark contrast to the future in store for many of her peers who haven’t finished secondary school and are already mothers. Sylvia has truly broken the mold, and unlike most of the young women who grew up in her neighborhood, she will make it to that next level of education. It is our hope that Moving the Goalpost and Planned Parenthood Global can continue to work together to inspire other similar girls to take ownership of their futures.

In Nairobi, PP Global partners with the Bravilian Queens, a nonprofit that organizes several teams in the newly established Nairobi Girls Soccer League. The program takes advantage of team practices, a time when a group of young women are gathered together, to provide basic sex education and answer any questions about puberty, sex, relationships and contraception.

Anne lives in one of the urban slums of Nairobi. To reach her home, one has to walk past an open latrine and then walk about 400 meters over a hill on a path littered with trash.

Here she is pictured with her parents and her younger sister.

Anne is not a Peer Counselor but one of the girls whose self-esteem is greatly benefited by her athletic prowess on the soccer field and her knowledge of her own reproductive health care needs.

Anne participates with great enthusiasm even though she does not have the funds to buy a pair of soccer shoes. She either borrows a spare pair when available or, in most cases, plays in knee socks and sandals.

This past year I had two opportunities to photograph in Kibera, Kenya, which is the second largest slum in Africa and the third largest in the world. Even though I have witnessed poverty, the physical landscape of Kibera was, to put it frankly, quite overwhelming.

The population of Kibera is estimated at 1.1 million people, up from 700,000 ten years ago. There is no infrastructure, no roads, no safe drinking water, or sewers. Kibera is created from scraps of tin and mud. The photographs presented here were all taken on my way to do work assignments in the AMREF Clinic (for the Novartis Malaria Initiative) and in the Tabitha clinic (for Planned Parenthood). All of the photos are “grab” shots. Some were taken from the vehicle that we used to get to the AMREF clinic. The car I was in had to inch it’s way along narrow muddy streets barely wide enough for our vehicle. Outside my window, people were going about their daily life not more than three feet away.

On my second trip to Kibera we walked to the clinic, and I had to be very mindful of each step to be sure I wouldn’t slip and fall into the mud and refuse. It was rather uncomfortable for me to take photos in these circumstances, as I felt that people really did not want to be photographed. It’s not my normal practice to work under these circumstances, but I felt obligated to document these living conditions and to share them with the outside world.

The poverty in Kibera was overpowering. Any solutions for alleviating or improving the situation here seemed to be beset by incredible complexities. I was recently at a conference on global health and food security at Stanford University, where I asked an expert in this field about dealing with the poverty found in large urban slums such as Kibera. He admitted that they had not discovered any effective strategy to deal with it.

I am hoping that this post will open a forum for ideas that readers may have in improving the living conditions found in places like Kibera. My impression was that whatever was being done was not effective; of course, the healthcare provided in the clinics I visited was very relevant and made a real difference in people’s lives; but when the population of Kibera has grown by 50 percent in 10 years, larger-scale solution are needed.

Below are a small sample of some of the photos and to see the complete portfolio in a larger format, please go to:

This is the concluding chapter in this series, and will focus on healthcare training and an AIDS clinic at the NKST church headquarters facility. Some personal impressions will follow the visual presentations.

The NKST reproductive-health project recently upgraded a center for educating midwives and nurses on reproductive-health issues, particularly basic family planning, contraceptive technology, and post-abortion-care services. The NKST education course produces a large pool of skilled family-planning attendants, whose outreach provides basic healthcare services to the wider community. Below is a series of photos taken in the classrooms.

This next series are photos taken in an AIDS clinic at the NKST facilities.

In my last night in Nigeria, I met with Dr. Mairo Mandara, director of the Packard Foundation programs, to go through a debriefing session on my experiences during the previous 10 days. She is a very bright, energetic, determined and outspoken woman, someone whom I greatly admire. I consider her, Thank-God Okosun, and some of the doctors I met to be true heroes. It would be easy for them to move to Europe or the U.S. and have a much easier life, but they are completely devoted to improving the quality of healthcare for so many of their fellow citizens; their hard-work and dedication is truly admirable.

I told Dr. Mandaro that Packard had indeed made progress in bringing family planning and post-abortion-care services to many communities, and that this changing cultural norms represented no small task . Apparently, I had only visited 20% of the projects that Packard had instituted in northern Nigeria, so the work that they had undertaken was even more widespread and extensive than what I was able to document. Yet, I told Dr. Mandara, there is so much work that remains to be done. The birth rate had been reduced to approximately 6 in the communities where they were working (as opposed to 10 or 12 before), which is definitley a big step in the right direction; nevertheless, without further reductions and better educational opportunities for children, it will be difficult for these communities to attain an improvement in their quality of life, and they will continue to struggle with poverty.

I asked Dr. Mandaro how much the Nigerian government contributes to women’s reproductive healthcare programs, and her answer left me quite speechless — it was precisely zero. To make really lasting changes in a country the size of Nigeria, these successful programs must be scaled up; however, without government support, it will be difficult to deliver the necessary education and family-planning programs to the millions of people who need them.

If I ran a large foundation, I would insist that the government match my annual budget by at least 5-10 times. Of course, this is my personal blog and opinion and in no way reflects the policies of the Packard Foundation or the realities that they may contend with. But I find it shameful that the government of Nigeria does not contribute any funds or programs in family planning. Despite the handicap of working without government support, Packard has made a significant contribution to the well-being of many communities in northern Nigeria.

So far I have been documenting family planning in Muslim communities in Northern Nigeria. This next post brings us back together with Thank-God Okosun and PPFA’s activities in an evangelical Christian community in Gboko, Benue State. The NKST (Nongo u Kristi u k Sudan hen Tiv) Church, whose headquarters we visited, has 127,115 members distributed among 298 well established congregations. As Nigeria provides little to no health care service for its citizens, the church had taken over this responsibility by being a health care provider; 9 hospitals and 123 primary health centers are managed by NKST.

The highly restrictive religious bias against reproductive health issues is a serious cause for concern in Nigeria. Most religious organizations view issues of reproductive health, particularly issues of sexuality and family planning, as immoral. Seven years ago PPFA was able to partner with the NKST church in altering this cultural and religious perception. Family planning, sex education and post abortion care are now accepted throughout the church and the fact that the church has a well established network of hospitals and clinics has made this PPFA project an effective one for reaching a large number of potential clients.

We arrived at the church headquarters as a large thunderstorm was brewing. The church compound is quite large, encompassing schools for both primary and secondary education, as well as those that train nurses and midwives and support several clinics.

As is the custom, we paid an honorary visit to the head pastor of the church upon our arrival. I photographed him by dim window light as there was no electricity in the building.

PPFA and Packard also made an advocacy visit to the leadership of NKST church to honor Rev. Inyonogie in appreciation for his contribution to the achievements of the family planning project. Here he is pointing to a painting of the founder of the NKST church.

A recess at the primary school in the church compound.

In the church. congregants are singing hymns before the start of the official PPFA program.

Church officer organizing PPFA donated contraceptive commodities. The materials also include MVA kits and Misoprostol. Manual vacuum aspiration (MVA) is a fast and safe way to empty the womb using a large syringe and cannula. It can be used to help a woman who has had a miscarriage or abortion that was not complete. Misoprostol is also used for incomplete abortions or miscarriages.

Prophylactics that will be distributed to the congregants.

Since the community is rather self contained ample opportunities for reproductive health care counseling exist.

The program takes advantage of normal everyday activities to distribute condoms. Go to the seamstress to get a dress made or an alteration and you also get a lecture on birth control and some prophylactics.

Similarly, go to the hairdresser, get counseling and free prophylactics.

A couple obviously anticipating using their new contraceptives.

Patients waiting to see health care worker at family planning clinic.

At the clinic, a couple receives counseling on family planning and they choose a method.

The introduction of family planning into a conservative religious community is no small achievement; changing cultural perceptions is a formidable task and we have to look no further than our own country to see how difficult it is to make lasting change. Packard and PPFA have successfully partnered in having family planning become a totally accepted way of life in the NKST communities.

In a small village an hour outside Kano I was asked to photograph a large congregation of people inside a small courtyard. Apparently this was the beginning of a wedding ceremony where Traditional Birth Attendants take the opportunity to dispense birth control materials and engage in family planning discussions. My initial impression was that there were more birth attendants than guests, but it was only the very beginning of the celebration.

Two experienced TBA’s from CEDPA ( Center for Development and Population Activities) were among the first guests.

Gathering of guests in the courtyard.

Traditional Birth Attendants gathered in one of the rooms adjacent to the courtyard. Frankly, I did not see much interaction between them and the guests. Perhaps they were planning their strategy, or more likely just resting before the guests arrived.

A few scenes from the courtyard:

A retired birth attendant.

A retired birth attendant, her colleague ( also retired) and her granddaughter.

Male Peer Counselors visit the marketplace to counsel males on the importance of family planning.

Finally, Pathfinder volunteers at a university in Kano dispensing information on AIDS prevention.

I will be completing this series of with two new posts on PPFA’s work in a Christian community in northern Nigeria.

Abortions are illegal in Nigeria; nevertheless, abortions occur and as they happen under non-medical conditions, serious complications are all too frequent. Murtala Mohammed Specialist Hospital (MMSH) is the primary public sector hospital in Kano State and has the largest program for treating women for complications of unsafe abortions. Although the hospital serves mainly woman in Kano, patients from neighboring Nigerian states and countries as far away as Mali and Niger seek treatment here as well. I was informed that due to lack of blood storage facilities, the MMSH is one of only three comprehensive obstetric care facilities in the state able to provide the full range of life saving obstetric services. Trained nurses and midwives treat women suffering from incomplete abortion with manual vacuum aspiration (MVA) in a dedicated procedure room. Care is available 24 hours a day. Women normally wait only 30 minutes to be treated, and most go home within an hour after treatment, after receiving counseling and choosing a contraceptive method.

MMSH is the only large scale hospital whose work in maternal health care that I documented. There were 3 very large hospitals where I was scheduled to work but was unable to do so for reasons that will become apparent at the end of this post.

Women waiting to be seen at MMSH

Health care worker recording patient information.

Patients and nurses in the ward for post-abortion care.

A patient undergoing Manual Vacuum Aspiration in the procedure room.

We also had the opportunity to visit the FOMWAN (Federation of Muslim Women’s Associations of Nigeria) Maternity Hospital in Kaduna. FOMWAN originally established the clinic in an area very close to an urban slum with the intent of treating women and children from this community. For religious reasons FOMWAN did not provide any family planning services. Pathfinder worked with community leaders to change this policy. Pathfinder’s programs are focused on reproductive health and family planning–specifically healthy timing and spacing of children for improved maternal and child health outcomes. As mentioned in previous posts, the fertility rate and the maternal mortality rate is extremely high in Northern Nigeria. Increased birth spacing plays a critical role in reducing maternal mortality.

The hospital is a maternal and child health facility and at least half the patients in these small wards were very young children. With the help of Pathfinder, the hospital was able to increase their capacity and treat a larger number of clients.

Maternal Health Care Coordinators in front of hospital.

Organizing patient records

The pharmacist.

Women and childrens wards.

As I mentioned, we visited three very large regional hospitals only to discover that there were no patients, only senior administrators. The wards were completely empty, no nurses, health care workers, just empty beds. The reason for this was shocking; the government refused to pay the employees, including all the doctors and nurses, a reasonable wage for their services. Consequently, all hospital employees were out on strike and the hospitals had shut down. This was quite unbelievable and it doesn’t take much imagination to picture the serious consequences. I have to say I find this situation quite incomprehensible. Here are two photos from a hospital showing the empty wards.